Abstract

Background: The American Heart Association recently amended their acute stroke guidelines to add recommendation for mechanical thrombectomy with stent retrieval in adults with proximal arterial occlusions. These guidelines further advise that stent retrieval may be reasonable for patients under age 18.

Case: We present the case of an 8 year old girl who demonstrated acute stroke symptoms on two occasions, 4 days apart, while therapeutically anticoagulated on Novalung iLA® . Thrombectomy was offered in both instances since the patient had a severe persistent deficit (NIHSS > 6), a clot in a proximal large artery, the procedure could be facilitated within 6 hours of symptom onset, anticoagulation precluded her from tPA administration, and CT showed uninfarcted brain tissue distal to the thrombus. On both occasions, thrombi were non-occlusive and successfully recovered with a Trevo stent retrieval device. No hemorrhagic complications were observed despite continuing anticoagulation during and between the procedures. Post-procedural assessment found respective decreases in the patient’s NIHSS score from 10 to 4 and 12 to 7.

Discussion: Treatment indications and immediate clinical benefits in our case are consistent with other thrombectomy cases reported. However, publication bias and the heterogeneity of paediatric cases make drawing conclusions about the safety and efficacy of thrombectomy in children difficult. Anticipating that recent changes to adult stroke guidelines would likely prompt paediatric stroke care providers to consider thrombectomy for their patients, our institution developed consensus-based guidelines for thrombectomy prior to the index case. This guideline served to facilitate multidisciplinary intervention and manage foreseeable risks.

Conclusions: Thrombectomy in our case was safely performed and resulted in improvement in immediate neurological outcomes. This case demonstrates the importance of engaging in partnerships with paediatric stroke providers and neurointerventionalists to establish consensus-based guidelines before offering thrombectomy to a child.